Getting to implementation: Adaptation of an implementation playbook

Abstract

IntroductionImplementation strategies supporting the translation of evidence into practice need to be tailored and adapted for maximum effectiveness, yet the field of adapting implementation strategies remains nascent. We aimed to adapt “Getting To Outcomes”® (GTO), a 10-step implementation playbook designed to help community-based organizations plan and evaluate behavioral health programs, into “Getting To Implementation” (GTI) to support the selection, tailoring, and use of implementation strategies in health care settings.MethodsOur embedded evaluation team partnered with operations, external facilitators, and site implementers to employ participatory methods to co-design and adapt GTO for Veterans Health Administration (VA) outpatient cirrhosis care improvement. The Framework for Reporting Adaptations and Modifications to Evidenced-based Implementation Strategies (FRAME-IS) guided documentation and analysis of changes made pre- and post-implementation of GTI at 12 VA medical centers. Data from multiple sources (interviews, observation, content analysis, and fidelity tracking) were triangulated and analyzed using rapid techniques over a 3-year period.ResultsAdaptations during pre-implementation were planned, proactive, and focused on context and content to improve acceptability, appropriateness, and feasibility of the GTI playbook. Modifications during and after implementation were unplanned and reactive, concentrating on adoption, fidelity, and sustainability. All changes were collaboratively developed, fidelity consistent at the level of the facilitator and/or implementer.ConclusionGTO was initially adapted to GTI to support health care teams' selection and use of implementation strategies for improving guideline-concordant medical care. GTI required ongoing modification, particularly in steps regarding team building, context assessment, strategy selection, and sustainability due to difficulties with step clarity and progression. This work also highlights the challenges in pragmatic approaches to collecting and synthesizing implementation, fidelity, and adaptation data.Trial registrationThis study was registered on ClinicalTrials.gov (Identifier: NCT04178096).

Application of the FRAME-IS to a multifaceted implementation strategy

“…For example, in several cases an adaptation could be characterized as a context change to both the format and personnel. Two previous studies described similar experiences when using the FRAME-IS to document adaptations to multifaceted implementation strategies supporting integration of practice-based interventions [13,14]. For example, Mangale et al [13] found that adaptations to the implementation strategies were not mutually exclusive and fit within several categories resulting in 'unavoidable overlap.…”

“…A small but growing number of studies have utilized the FRAME-IS to provide important information on the adaptability of various implementation strategies in diverse settings including FQHCs [6,[13][14][15][16]. However, most of these studies are limited by their focus on a discrete implementation strategy (e.g., training), which do not reflect the complexity of multifaceted strategies such as practice facilitation (PF).…”

Application of the FRAME-IS to a Multifaceted Implementation Strategy

“…Two previous studies described similar experiences when using the FRAME-IS to document adaptations to multifaceted implementation strategies supporting integration of practice-based interventions. ( 13 , 14 ) For example, Mangale et al( 13 ) found that adaptations to the implementation strategies were not mutually exclusive and fit within several categories resulting in ‘unavoidable overlap.’ Haley et al ( 9 ) also described challenges to tracking adaptations to a multifaceted implementation strategy using existing frameworks. Like our approach, the authors addressed these challenges by adding more detailed information on the changes using the ERIC taxonomy and developed new codes to augment the broad categorization of strategies offered by current frameworks.…”

“…Two previous studies described similar experiences when using the FRAME-IS to document adaptations to multifaceted implementation strategies supporting integration of practicebased interventions. (13,14) For example, Mangale et al (13) found that adaptations to the implementation strategies were not mutually exclusive and t within several categories resulting in 'unavoidable overlap.' Haley et al ( 9) also described challenges to tracking adaptations to a multifaceted implementation strategy using existing frameworks.…”